Shoulder Dystocia

1 Shoulder Dystociaby Henry Lerner, available in PDF formatTable of Contentsclick on links to view sections or scroll down for entire Introduction to Shoulder Dystocia2. History of Shoulder Dystocia3. What is Shoulder Dystocia ?4. Pelvic Anatomy Related to Shoulder Dystocia5. Incidence of Shoulder Dystocia6. Recurrent Shoulder Dystocia7. Neonatal Injuries Following Shoulder Dystocia8. Can Shoulder Dystocia be Anticipated Accurately?9. Are There any Strategies that can Reduce theChances of a Shoulder Dystocia Occurring?10. Can Shoulder Dystocia be Resolved Without FetalInjury When It Does Occur? The Management ofShoulder Dystocia11. Is all Brachial Plexus Injury Caused by ShoulderDystocia and/or Excessive Physician Traction?

2 12. Shoulder Dystocia Training13. Documentation14. Conclusions15. BibliographyIntroductionThe greatest nightmare an obstetrician is likely to face is shoulderdystocia. At an otherwise normal delivery, just after the baby'shead has emerged, the neck suddenly retracts back against themother's perineum causing the baby's cheeks to puff out. Theexperienced obstetrician knows at this point that the baby'santerior Shoulder is caught on the mother's pubic bone and that ifhe or she is unable to free up the Shoulder within a few minutesthe baby will suffer irreversible brain damage or Dystocia occurs in approximately of alldeliveries. Given that there are roughly 3 million babies bornvaginally each year in the United States, this deliverycomplication will be experienced by roughly 15,000-45,000women a year.

3 The larger the baby, the more likely it is to , even with very large babies Shoulder Dystocia occursonly occasionally and sporadically. Therefore a physician neverknows when it will be encountered. The most common serious complication following a shoulderdystocia delivery is brachial plexus injury. This is when the nervesin a baby's neck--the brachial plexus are temporarily orpermanently damaged. The nerves of the brachial plexus controlthe function of the arm and hand. Injury to the upper part of thebrachial plexus is called Erb palsy while injury to the lower nervesof the plexus is called Klumpke palsy. Both can cause significant,lifelong disability. Because of the gravity and unexpectedness of Shoulder Dystocia ithas long been a major area of obstetrical concern.

4 Yet despite thehundreds of published studies about Shoulder Dystocia there arestill multiple, important recurrent questions: Is Shoulder dystociapredictable? Can it be prevented? Is there anything that can bedone when it does occur to deliver the baby without brachialplexus nerve damage? If there is an injury, was it caused bymismanagement on the part of the clinician or was it aninevitable consequence of the Shoulder Dystocia ?The interest obstetricians have in these questions has beenheightened in the last two decades by the increasing influence ofmedical-legal issues on the practice of medicine. As regardsshoulder Dystocia , it is frequently the case that when a brachialplexus injury occurs, an obstetrician will be charged withnegligence.

5 Such claims are now so frequent that law suitsrelated to Shoulder Dystocia deliveries constitute the secondlargest category of indemnity payments in obstetrics, exceededonly by birth asphyxia. In their defense, physicians contend thatshoulder Dystocia is a totally unpredictable event and that evenwith perfect management brachial plexus injuries will occur. Where does the truth lie?This web site represents an attempt to answer this and otherquestions about Shoulder Dystocia . By having thoroughlyreviewed the published literature on Shoulder Dystocia andbrachial plexus injury from 1965 to the present, it has beenpossible to frame comprehensive and consistent answers to themajor questions that bedevil this area of obstetrics.

6 It is the hopeof the author that the information presented here about thecause, preventability, and culpability for Shoulder Dystocia andbrachial plexus injuries will (1) aid in improving the care given towomen and their babies and (2) will help to fairly adjudicateresponsibility in medical liability cases in which a baby has beeninjured during a Shoulder Dystocia delivery. Imortant new documentA recent report by the American College of Obstetricians andGynecologist (2014) entitled Neonatal Brachial Plexus Palsy,written by a panel of the leading experts on Shoulder dystociaand brachial plexus palsy from across the country, has addedmuch specific information and informed opinion to the discussionof Shoulder Dystocia and brachial plexus palsy.

7 This document canbe ordered at phenomenon of Shoulder Dystocia has long been , one of the earliest physicians specializing in obstetrics,described a situation he encountered in 1730 as follows:Called to a gentlewoman in labor. The child's headdelivered for a long time but even with horridpulling from the midwife, the remarkably largeshoulder prevented delivery. I have been called bymidwives to many cases of this kind, in which thechild was frequently in 1955 gave what is now a classic description of shoulderdystocia:The delivery of the head with or without forceps mayhave been quite easy, but more commonly there hasbeen a little difficulty in completing the extension ofthe head. The hairy scalp slides out with the forehead has appeared it is necessary topress back the perineum to deliver the face.

8 Fatcheeks eventually emerge. A double chin has to behooked over the posterior vulvar commisure, towhich it remains tightly opposed ..Time passes. The child's face becomes suffused. Itendeavors unsuccessfully to breathe. Abdominalefforts by the mother and by her attendants produceno advance. Gentle head traction is equallyunavailing. Usually equanimity forsakes theattendants they push, they pull. Alarm , "by greater strength of muscle or bysome infernal juggle," the difficulty appears to beovercome, and the Shoulder and trunk of a goodlychild are delivered. The pallor of its body contrastswith the plum-colored cyanosis of the face, and thesmall quantity of freshly expelled meconium aboutthe buttocks.

9 It dawns upon the attendants that theiranxiety was not ill founded, the baby lies limp andvoiceless, and only too often remains so despite allefforts at the most famous case of brachial plexus injury was thatinvolving Prince William of Germany who subsequently becameKaiser Wilhelm II in 1888. It seems that William was in breechposition at birth and was manipulated by several physicians and amidwife during delivery. Apparently the baby was not breathingwhen it emerged, but by "continuous rubbing .. dousing in ahot bath, and a series of short, sharp slaps on his buttocks" thedoctors managed to get the child to third day after delivery the midwife noticed that William's leftarm was slack. It was thought that the arm had been "wrenchedout of the socket" and some of the muscle tissue torn.

10 Most likely,William suffered a brachial plexus injury. In addition it issuspected that there were several moments of asphyxia whichmight have caused slight brain damage. It has been postulatedthat this was the cause of William's later hyperactivity andemotional instability. He may also have suffered slight cerebralpalsy. For the rest of his life, William's "withered" left arm wasconcealed from the public by careful posing for is Shoulder Dystocia ? Shoulder Dystocia occurs when, after delivery of the fetal head,the baby's anterior Shoulder gets stuck behind the mother's pubicbone or, occasionally, the baby s posterior Shoulder impinges onthe mother s sacrum. If this happens, the remainder of the babydoes not follow the head easily out of the vagina as it usuallydoes during vaginal simple definition of Shoulder Dystocia , however, glosses overmany complexities.